Medical History

Medications (including prescriptions, over the counter medications and vitamins)

Short text field

Do you smoke?

YesNo

If yes, how many packs per day?

How long have you been smoking?

Do you drink alcohol?

YesNo

If yes, what do you drink?

How many drinks per day?

Please mark the appropriate box and if applicable, detail any specific problems you have had.

Weight Gain/Loss

YesNo

Specific Problems

Vision Trouble

YesNo

Specific Problems

Asthma

YesNo

Specific Problems

High Blood Pressure

YesNo

Specific Problems

Thyroid

YesNo

Specific Problems

Diabetes

YesNo

Specific Problems

Skin Conditions

YesNo

Specific Problems

Liver Problems

YesNo

Specific Problems

Bleeding Problems

YesNo

Specific Problems

Heart Condition

YesNo

Specific Problems

Circulation Disorders

YesNo

Specific Problems

Chest Pain

YesNo

Specific Problems

Lungs (TB, Pneumonia)

YesNo

Specific Problems

Swelling in legs, a nkles and/or feet

YesNo

Specific Problems

Stomach Problems

YesNo

Specific Problems

Arthritis (if so, what type?)

YesNo

Specific Problems

Stroke(s)

YesNo

Specific Problems

Gout

YesNo

Specific Problems

Numbness in legs/feet

YesNo

Specific Problems

Muscle Cramping

YesNo

Specific Problems

Lower Back Pain

YesNo

Specific Problems

Depression

YesNo

Specific Problems

Psychiatric Issues

YesNo

Specific Problems

Kidney Stones

YesNo

Specific Problems

Other Ilnesses or Problems

YesNo

Specific Problems

Please indicate if any of your immediate family members have had the following health related issues:

Cancer

Diabetes

Stroke

Arthritis

Kidney Disease

Cardiovascular Disease

Mental/Emotional Disorders

I have read this form and answered the questions to the best of my ability. I authorize Dr. Cullen to examine and treat me. I also authorize Omaha Foot and Ankle Specialists to furnish any and all information to my insurance company in regards to this appointment and all subsequent appointments I have at this office. I acknowledge that I am responsible for payment in full for services rendered.

Signature

Date

HIPAA Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.
“Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health condition and related health care services.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION: Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
TREATMENT: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care for you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
PAYMENT: Your protected health information will be used, as needed, to obtain payment, and will be disclosed to health plans to obtain approval for the hospital admission.
HEALTHCARE OPERATIONS: We may disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training medical students, licensing and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as required by law, Public Health issues as required by law, Communicable Diseases; Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors and Organ Donations: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500. Other Permitted Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke this authorization at any time, in writing, except to the extent that your physician or the physician’s practice has taken action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS: The following is a statement of your rights with respect to your protected health information: You have the right to request a restriction of your protected health information. This means you may ask us to not use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operation. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care of for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction apply to.
Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted, and then you have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively (i.e. electronically).
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you a copy with any such rebuttal.
You have the right to receive any accounting of certain disclosure we have made, if any, of your protected health information. You have the right to object or withdraw as provided in this notice.
Complaints: You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number.
Signature below is only acknowledgement that you have received this notice of our Privacy Practices:

Signature

Date

Office Policies

All co-pays must be paid upon check-in for an appointment.

If you are more than 20 minutes late for an appointment, you may be asked to reschedule.

We understand your time is just as valuable as ours, and we do our best to stay on time. However, some times patient visits and surgical procedures take longer than expected which may result in some delays. We ask for your patience and understanding.

O.F.A.S. will charge a $25 fee for all returned checks.

There is a $5 per page documentation fee for all paperwork requiring Doctor correspondence and/or signatures on any FMLA, surgical or insurance related issues.

O.F.A.S. reserves the right to charge a $50 cancellation fee for appointments cancelled with less than a 24 hour notice or an appointment no show.

FINANCIAL POLICY : Payment is due at time of service . We will submit claims to your insurance provider, however, i f your deductible and/or out -of pocket maximum has not been met, payment for the visit will be collected upon check out from your appointme nt . If you are unable to pay the full amount due, payment arrangements will need to be made at that time. We are a small office and are dependent on all patient payments, no matter how small, to continue functioning on a day -to - day basis. Therefore, w e subscribe to an aggressive payment recovery system in order to obtain payments from our patients. If there is an outstanding balance on your account after 30 days , you will start receiving a series of letters and/or phone calls requesting payment until the balance is paid in full. On any account balance of 6 0 days or more, a $39 administrative fee will be assessed and the account will be turned over to a collection agency .

When your appointment was made, you provided us with a landline and/or cell phone number(s). By doing so, you give your consent to any of Omaha Foot and Ankle Specialists’ operations or independent business partners who do work on Omaha Foot and Ankle Specialists’ behalf. This includes our billing and collection agents who may contact you at these numbers, or at any number that is later acquired for you, to leave live or prerecorded messages regarding any accounts or services. For greater efficiency, these calls may be delivered by an auto dialer. However, providing us a landline or cell phone number is not a condition of receiving our services.

MEDICARE: Medicare covers many procedures and treatments we provide based upon diagnostic criteria. Medicare does not pay for “routine foot care” (trimming nails, corns and calluses) for healthy individuals. Medicare determines who needs and is covered for routine foot care based upon patient health factors and systemic conditions, such as diabetes and vascular issues. Payment of routine foot care not covered by Medicare will be the patient’s responsibility.

PATIENT ACKNOWLEDGEMENT
I have read and understand the information provided above. I authorize Dr. Cullen and/or Dr. Sikes to examine and treat me. I acknowledge that I am responsible for payment in full for services rendered. Should my insurance company pay me directly for services received, I will assign my insurance benefits to Omaha Foot and Ankle Specialists.